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THE EFFECTS OF A 7-WEEK PRACTICAL BLOOD FLOW

RESTRICTION PROGRAM ON WELL-TRAINED


COLLEGIATE ATHLETES
PAUL E. LUEBBERS,1 ANDREW C. FRY,2 LUKE M. KRILEY,1

AND

MICHAEL S. BUTLER1

Department of Health, Physical Education, and Recreation, Emporia State University, Emporia, Kansas; and 2Department of
Health, Sport and Exercise Sciences, University of Kansas, Lawrence, Kansas
ABSTRACT

INTRODUCTION

Luebbers, PE, Fry, AC, Kriley, LM, and Butler, MS. The effects of
a 7-week practical blood flow restriction program on well-trained
collegiate athletes. J Strength Cond Res 28(8): 22702280,
2014The purpose of this study was to examine the effects of
a 7-week practical blood flow restriction (BFR) protocol used in
conjunction with a strength training program on measures of muscular strength and size in collegiate American football players.
Sixty-two participants were divided into 4 groups. Three groups
completed a traditional upper- and lower-body split strength program. Two of these groups also completed supplemental lifting
sessions. Of these 2, 1 completed the additional lifts with BFR.
The final group completed a modified training program, followed
by the supplemental lifts, with BFR. The supplemental lifting protocol consisted of bench press and squat, using 20% 1 repetition
maximum (1RM) for 4 sets with 30 repetitions performed in the
first set and 20 repetitions performed in the following 3 sets. Each
set was separated by 45 seconds of rest. The supplemental bench
press was completed at the end of upper-body days and the squat
at the end of lower-body days. Dependent measures were taken
before the start of the program and again on conclusion the following dependent variables were measured: upper- and lowerbody girths, 1RM bench, and squat. Results of a 4 3 2 mixedmodel multivariate analysis of covariance revealed a significant
difference for the interaction on the dependent variables. Followup univariate analysis of variances indicated a significant difference
for 1RM squat. This suggests that a practical BFR program used in
addition to a traditional strength training program can be effective at
increasing 1RM squat performance. The use of elastic knee wraps
makes BFR a feasible training option for coaches and athletes.

KEY

WORDS

KAATSU,

occlusion,

strength

training,

hypertrophy

Address correspondence to Paul E. Luebbers, pluebber@emporia.edu.


28(8)/22702280
Journal of Strength and Conditioning Research
2014 National Strength and Conditioning Association

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esistance training has many known athletic benefits, including reducing the risk of injury, enhancing
muscular endurance, improving power, promoting
speed development, and increasing muscular
strength. Although many forms of resistance training exist,
weight training has long been a staple among coaches and
athletes for eliciting improvements in muscular fitness.
Traditional weight training program design calls for the
utilization of light weight and high repetitions for increasing
muscular endurance (e.g., ,60% 1 repetition maximum
[1RM] for multiple sets of 10 or more repetitions), whereas
increases in muscular size and strength are generally pursued
with the use of heavy weight and a low number of repetitions (e.g., .70% 1RM for several sets of 6 repetitions or less)
(1,6,11). However, present-day research has demonstrated
that weight training with light weight and high repetitions
can result in significant increases in muscle size and strength
when it is used in conjunction with blood flow restriction
(BFR). These observations have been made in healthy,
untrained, and recreationally trained participants (2,31,32,39)
and in athletic populations (3,30,36).
Blood flow restriction training (also known as occlusion
training) is the act of reducing the amount of arterial blood
flow to the working muscles while occluding venous return
(8,25). This is achieved by placing a wrapping device around
the proximal end of the muscles in which the restriction is
desired. The resultant decreased delivery and cessation of
return is believed to be responsible for many of the proposed
mechanisms for the efficacy of BFR training in promoting
muscular strength and hypertrophy. The most prevalent theories stem from the reduced oxygen availability and metabolite accumulation in the affected muscles. This low-oxygen
high-metabolite environment has been demonstrated to
increase the recruitment of high-threshold motor units
(31,37), which are typically only recruited under heaving
loading conditions (14,28). In addition, some research has
indicated that there can be an exaggerated growth hormone
release after BFR training (10,27,29), although the role
played by systemic growth hormone in hypertrophy has
been challenged in recent years (34).

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However, these mechanisms cannot account for some
circumstances in which BFR has been shown to be
beneficial, as much of the BFR research uses modalities
other than resistance training. In 2000, Takarada demonstrated that static BFR was effective in attenuation of muscle
loss in bedridden patients recovering from anterior cruciate
ligament surgery. Being nonambulatory negates the recruitment of any muscle fiber type, and metabolic build-up is
negligible. A similar study conducted by Kubota in 2008 also
demonstrated an offsetting of thigh muscle atrophy in
movement-restricted participants receiving a BFR treatment
(16). Abe et al. (4) observed increased muscular strength and
hypertrophy by using BFR in combination with slow treadmill walking. Although Abe did not measure metabolites,
Loenneke et al. (23) conducted comparable research in
which lactate was assessed. Analysis revealed that slow
treadmill walking using BFR did not result in metabolite
accumulation. So, although increased motor unit recruitment and metabolite build-up may play a role in the positive
muscular adaptations seen with BFR training, it is apparent
that there are other mechanisms involved.
Loenneke et al. (18,20) have theorized that muscle cell
swelling may be an important factor. The decreased arterial
delivery and cessation of venous return during a BFR application lead to a pooling of blood in the muscles distal to the
application site of occlusion. This pooling effect could cause
a shift in intra- and extracellular fluids leading to an increase
in muscle cell volume. Haussinger et al. (12) first theorized
that cell swelling may induce an anabolic response, and
follow-up work supports the concept (7,15). This mechanism may explain why BFR seems to attenuate muscle atrophy during times of immobilization where there is an
absence of exercise and/or metabolite accumulation. It
would appear that this may be the 1 consistent factor across
all modalities of BFR training.
To obtain BFR, most research studies have used pneumatic wrapping devices, such as a KAATSU Master (Sato
Sports Plaza Ltd., Tokyo, Japan), or modified blood pressure
cuffs, which allow for precise control of the amount of
applied pressure. Although pneumatic devices allow for
control of the pressure during BFR training, generally, they
are not practical for use outside of a clinical or laboratory
situation because of being cost prohibitive and/or limited in
accessibility. In 2009, Loenneke and Pujol (22) proposed the
use of elastic knee wraps for BFR training (i.e., practical
BFR), which would make the method a feasible option for
general use. Quantification of the pressure exerted by a taut
elastic wrap in a real-world setting is not possible; therefore,
it was suggested that pulling the wraps tight to a moderate
perceptive pressure (e.g., a 7 on a scale of 0 to 10) would be
sufficient. This protocol has since been shown to be effective
in occluding venous return while sufficiently reducing arterial delivery (35).
It is clear that the literature supports the efficacy of BFR
training for promoting positive muscular adaptations across

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a variety of populations and modalities. However, few


studies have used elastic knee wraps (17,21,23,24,36), and
even fewer have used them outside of a laboratory setting
with an athletic population (36). Additional research in this
area will provide further insight into the use of practical BFR
in those who are already well trained.
The purpose of this study was to examine the effects of
a 7-week practical BFR protocol used in conjunction with
a traditional weight training program on measures of
muscular strength and size in collegiate American football
players. The protocol used in this investigation was modeled
after a practical BFR study conducted by Yamanaka et al.
(36), which also used an American football team. This study
was a field experiment conducted during the teams offseason, as a part of their strength and conditioning program.
It was hypothesized that those who completed the traditional training program, in combination with the supplemental lifting protocols, under conditions of practical occlusion
would experience greater gains in muscular strength and size
than those in the other treatment groups.

METHODS
Experimental Approach to the Problem

This investigation employed a pretest-posttest mixed model


design with a training intervention. Participants were recruited from a National Collegiate Athletic Association
(NCAA) Division II American football team, from which
72 players volunteered to take part. All participants completed a 7-week off-season football strength and conditioning program. Before the start of the program, and again on
conclusion, the following dependent variables were measured: upper- and lower-body girths, and strength as
determined by 1RM bench press and squat.
There were 4 groups of participants in this study. The
football coaching staff was aware that the experimental
design called for one of the groups training program to be
modified in such a way that its members would not complete any high-intensity lifting. They expressed concern
about restricting players who held the traditional strength
and power positions (linemen and linebackers) from highintensity work. Their concern was addressed by removing
those positions from the initial selection pool and forming
the modified group (M/S/R) from the remaining subset of
players. Once the modified group was established, the linemen and linebackers were returned to the selection pool
with the other remaining players and randomly assigned
among the other 3 groups (H/S/R, H/S, and H). For a complete description of these groups, see Training Protocols and
Groups.
Subjects

The football program was a part of the Intercollegiate


Athletics Department at a midwestern regional university.
Permission to conduct the study was granted by the
universitys institutional review board. The coaching staff
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Practical Blood Flow Restriction


of the football team agreed to the recruitment of participants
from the team and allowing the necessary modifications to
be made to the strength and conditioning program. Details
of the study were verbally explained to the entire team by
the principal investigator at a team meeting. Seventy-two
team members volunteered to be participants. Each participant signed an informed consent document. All were
deemed healthy and able to train by the universitys medical
and athletic training staff.
The off-season training program took place during an
academic semester and lasted for 7 weeks, with 4 training
days each week2 upper-body days and 2 lower-body days.
Players were assigned by their coaches to attend 1 of 3
training sessions each day, based on their class schedules.
Training sessions were held at 7:15 AM, 1:30 PM, and 3:30 PM.
The study began with 72 participants (18 in each group).
Because of non-BFR related injuries or lack of compliance
with the protocol, 10 players were removed from the study.
Complete data were collected on the 62 remaining participants (20.3 6 1.1 year old, 99.1 6 19.7 kg, and 7.1 6 2.2
years of weight training experience).
Procedures

Pretests and Posttests. All participants attended pretest and


posttest sessions for assessment of dependent variables. Both
the pretests and posttests were split between 2 days. Pretest
Day 1 was comprised of upper- and lower-body girths and
1RM bench press. Body mass was measured for descriptive
and statistical purposes. This session was completed after 48
hours of rest. Pretest Day 2 followed the next day and
consisted of the 1RM squat test. The same measures were
again taken at the posttest sessions, which were completed at
the conclusion of the program. Posttest day 1 took place after
48 hours of rest, followed by posttest day 2, taking place the

very next day. All pretests and posttests took place during the
participants regular training session time. Figure 1 provides
a schematic of the testing and training sessions.
Body Mass and Girths. Body mass was measured with a Tanita
WB-3000plus Digital Physicians Scale (Arlington Heights,
IL, USA). The American College of Sports Medicine
protocols for measuring circumferences were used for
assessing arm and thigh girths (13). Chest girth was determined by placing the tape horizontally around the torso at
the level of the nipple, and measurement was taken at the
end of normal exhalation. All measurements, both pre and
post, were assessed using a Gulick tape measure and were
taken by the same investigator, whose test-retest reliability
was 0.55% coefficient of variation (CV) for the arm, 0.47%
CV for the thigh, and 0.48% CV for the chest.
1 Repetition Maximum Tests. Maximal strength for bench
press and squat were assessed following procedures set forth
by the football coaching staff. Players completed 1 warm-up
set of 10 repetitions using approximately 40% of their
estimated 1RM and a second warm-up set of 5 repetitions
using approximately 60% of their estimated max. After
adequate rest, players loaded the bar with approximately
8085% of their estimated 1RM and completed 1 repetition.
Weight was added with each subsequent 1 repetition set
until the player could no longer complete a repetition correctly. The 1RM was determined as the last weight used in
which the participant successfully completed the lift with
proper form through the entire range of motion, as defined
by National Strength and Conditioning Association (NSCA)
(5). Conditions between the pre- and posttest 1RMs were made
as identical as possible (see discussion above and Figure 1).
Wearing a weightlifting belt was encouraged, but not required.

Figure 1. Testing and training schematic.

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TABLE 1. Groups, training programs, and protocols.*


Group

Modified program
(M)

H/S/R
H/S
H
M/S/R

Traditional high-intensity
program (H)

Supplemental 20% 1RM


protocol (S)

Blood flow restriction


(R)

*1RM = 1 repetition maximum.

Players who chose to wear a belt for a pretest 1RM also wore
a belt for the posttest 1RM. The same was true for those who
chose not to wear a belt. All 1RM tests, both pre and post, were
supervised by the same members of our research team, each of
whom is a NSCA Certified Strength and Conditioning Specialist (CSCS). Test-retest reliability as determined by our research
team for the 1RM bench press was 0.62% CV and 0.35% CV for
the 1RM squat.
Each of the 4 groups completed a different training protocol
and/or training intervention, an overview of which can be
found in Table 1. Details of each can be found below and
examples can be found in Tables 2 and 3.

repetition sets with high %1RM). While the intricacies of the


program changed over the course of the 7 weeks, at its
foundation were lifts traditionally used in American football
programs: bench press, overhead press, power cleans, squats,
and variations of each. Auxiliary lifts, such as bicep curls,
triceps extensions, calf raises, and abdominal work were also
included. Training was split into alternating upper- and
lower-body days, each being trained twice per week,
although not always in the same sequence. There were 4
training days per week, occurring on Mondays, Tuesdays,
Thursdays, and Fridays. Tables 2 and 3 provide representative workouts for lower- and upper-body days. The program
followed this lifting format for the duration of the 7-week
program.

Traditional High-Intensity Training Program (H). In brief, this


was a weightlifting program focused largely on increasing
strength. It used sets, repetitions, and loading schemes
of traditional high-intensity programs (i.e., multiple low-

Modified Training Program (M). This protocol was identical to


the traditional training program, with the exception that
high-intensity bench press, squat, and their variations were
excluded (Tables 2 and 3).

Training Protocols and Groups

TABLE 2. Representative lower-body day for each group: Total volume-load.*


Exercise
Squat

Lateral squats
Good mornings
DB lunges
Glute-Ham raises
Supplemental squats

Set

Rep

Load (kg)

1
1
1
1
1
3
3
3
3
1
3

8
6
4
2
2
5
6
8
6
30
20

130 (65%)
140 (70%)
160 (80%)
170 (85%)
180 (90%)
130 (65%)
45.5
22.7
11.4
40 (20%)
40 (20%)

Total vol-load (kg)

H/S/R
Vol-load

H/S
Vol-load

H
Vol-load

1,040
840
640
340
360
1,950
819
544.8
205.2
1,200
2,400
10,339

1,040
840
640
340
360
1,950
819
544.8
205.2
1,200
2,400
10,339

1,040
840
640
340
360
1,950
819
544.8
205.2
6,739

M/S/R
Vol-load

819
544.8
205.2
1,200
2,400
5,169

*Participants with a 200 kg 1RM squat.


DB = dumbbell.

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Practical Blood Flow Restriction

TABLE 3. Representative upper-body day for each group: Total volume-load.*


Exercise
Bench press

Lockout press
Upright rows
Single-arm DB rows
Tricep DB extensions
DB hammer curls
Supplemental bench

Set

Rep

Load (kg)

1
1
1
1
1
4
3
3
3
3
1
3

8
6
4
2
2
2
6
8
10
10
30
20

81 (65%)
87.5 (70%)
100 (80%)
106.25 (85%)
112.5 (90%)
81 (65%)
45
45.5
25
22.7
25 (20%)
25 (20%)

Total vol-load (kg)

H/S/R
Vol-load

H/S
Vol-load

H
Vol-load

650
525
400
215
225
650
810
1,092
750
681
750
1,500
8,248

650
525
400
215
225
650
810
1,092
750
681
750
1,500
8,248

650
525
400
215
225
650
810
1,092
750
681
5,998

M/S/R
Vol-load

810
1,092
750
681
750
1,500
5,583

*Participants with a 125 kg 1RM bench press.


DB = dumbbell.

Supplemental 20% 1 Repetition Maximum Lifting Protocol (S).


Participants completed these sessions together, at the same
time, at the conclusion of their training workouts. All
sessions were supervised by the same 2 primary researchers
to ensure compliance. The supplemental squats were
performed at the end of lower-body training days, and the
supplemental bench press was performed at the end of upperbody days. Barbell load was set at 20% of pretest 1RM. A list
of each participants barbell load was posted at each lifting
station to ensure correct loads were used. Players completed
1 set of 30 repetitions followed by 3 sets of 20 repetitions, with
45 seconds of rest between each set (Tables 2 and 3). The
pace of the concentric and eccentric phases of each repetition
was set at 1.5:1.5 seconds. This cadence was guided by a series
of ascending and descending tones that were played through
the weight rooms stereo system from a prerecorded .mp3 file.
All 4 sets, including the rest periods, were incorporated into
the .mp3 file and verbal instructions for the sessions. This
provided consistency between all sessions throughout the
duration of the program and allowed for the investigators to
closely monitor the participants for compliance.
Practical Blood Flow Restriction (R). Restriction of blood flow
in the participants receiving the occlusion treatment was
accomplished with the use of powerlifting elastic knee wraps
with hook-and-loop closure (Grizzly Fitness, Kitchener, ON,
Canada). The wrap dimensions were 7.6 3 167.6 cm (3.0 3
66.0 in) and were graduated every 1.3 cm (0.5 in) perpendicular to the edge with a silver permanent marker. For the
BFR bench press, the wraps were applied to the proximal end
of the upper extremities (above the bicep, below the deltoid).
For the BFR squat, the wraps were applied at proximal end of
the lower extremities (at the top of thigh, near the inguinal

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crease). The wraps were initially applied without tension, but


secure enough to remain in place. Just before the start of the
lifting session, the wraps were pulled to a 7.6 cm (3.0 in)
overlap as measured by the silver markings and secured. This
tension was maintained for the entire 4-set lifting session,
including the rest periods. The wraps were removed immediately at the conclusion of the lifting sessions.
H/S/R Group. This group completed the traditional highintensity training program (H) and the supplemental 1RM
lifting protocols (S). They did so with the wraps in place,
under conditions of practical BFR (R).
H/S Group. This group completed the traditional highintensity training program (H) and the supplemental 1RM
lifting protocols (S). However, they did not use the wraps;
therefore, they did not receive the BFR treatment.
H Group. This group completed only the traditional highintensity training program (H). They did not participate in
the supplemental lifting sessions and at no time did they use
the wraps.
M/S/R Group. This group completed the Modified Training
Program (M). At the end of these sessions, they also
completed the supplemental 1RM lifting sessions (S) and
did so under conditions of practical BFR (R).
Training Sessions. To accommodate players class schedules,
the athletes were assigned by their coaches to attend 1 of the
3 training sessions each day. Training sessions were held at
7:15 AM, 1:30 PM, and 3:30 PM. Members of each training
group were present during all training sessions.

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dependent variables, Wilks L = 0.606, F (15, 146.711) =


1.943, p = 0.023, multivariate 2 = 0.154. To follow-up the
significant MANCOVA on the interaction, separate univariate ANOVAs were conducted on each of the 5 dependent
variables. Only one of the follow-up ANOVAs showed a sigStatistical Analyses
nificant effect. A significant interaction was found for 1RM
A 4 3 2 mixed-model multivariate analysis of covariance
squat, F (3, 57) = 6.460, p = 0.001, 2 = 0.254 (Figure 2). To
(MANCOVA), with training groups serving as the
help interpret the interaction, a 1-way ANOVA was combetween-factor, pre- and posttests as the within-factor, and
puted on the change scores for the 1RM squat. This
body mass as the covariate was performed using PASW
ANOVA showed a significant difference between groups,
Statistics 18. The level of significance was set at 0.05. SepaF (3, 58) = 6.00, p = 0.001. Results of Fisher LSD post hoc
rate univariate 1 3 4 analysis of variance (ANOVA) tests
tests revealed that the H/S/R group experienced greater
were conducted on each dependent variable as a follow-up
gains in 1RM squat performance than did the M/S/R group
test for any significant main effects from the MANCOVA.
(p , 0.000), the H/S group (p = 0.025), and the H group
The univariate follow-up ANOVA tests were also mixed
(p = 0.009).
model with training groups serving as the between-factor
MANCOVA results revealed no significant difference
and pre- and posttests as the within-factor. Post hoc tests
for the group factor on the dependent variables, Wilks
were conducted to examine any significant effects from the
L = 0.75, F(15, 146.711) = 1.10, p = 0.360, multivariate 2 =
univariate ANOVAs.
0.093. MANCOVA results also revealed no significant difference for the time factor on the dependent variables, Wilks
RESULTS
L = 0.830, F(5, 53) = 2.172, p = 0.071, multivariate 2 = 0.170.
The means and SDs are listed in Table 4. MANCOVA results
Because the MANCOVA showed a nonsignificant main
revealed a significant difference for the interaction on the
effect for group, follow-up analyses were not required.
However, to better understand
how current results compare to
those of Yamanaka et al. (36),
additional analyses were conTABLE 4. Girth and strength measures.
ducted on 1RM bench press
performance and circumferPretest
Posttest
ence measures.
Group
N
Mean
SD
Mean
SD
Mean change
For 1RM bench press, dependent
t-tests were run to examine
Arm (cm)
changes from pre- to posttest
H/S/R
17
34.7
3.0
35.3
3.0
0.52
H/S
14
36.3
3.8
36.7
3.7
0.49
for the dependent variables,
H
15
35.6
3.0
36.4
3.1
0.78
and a 1 3 4 ANOVA was conM/S/R
16
31.7
1.8
31.6
3.2
20.16
ducted on change scores, which
Chest (cm)
is a comparable analysis to the
H/S/R
17
102.2
10.3
101.7
9.7
20.57
independent t-tests performed
H/S
14
107.1
13.9
106.5
11.4
20.58
H
15
106.5
11.8
107.3
10.6
0.76
by Yamanaka et al. on percent
M/S/R
16
95.0
3.4
94.9
3.1
20.01
change. Although the t-test on
Thigh (cm)
1RM bench revealed that there
H/S/R
17
59.5
4.7
61.5
3.9
1.98
was a significant increase across
H/S
14
61.1
5.1
63.1
5.9
2.04
groups (t(1,61) = 6.713, p ,
H
15
60.6
6.2
62.9
6.6
2.36
M/S/R
16
55.6
3.3
57.3
2.6
1.71
0.000), the ANOVA did not
Bench press (kg)
detect differences between the
H/S/R
17
123.3
20.7
132.0
24.4
8.69
groups (F(3,58) = 1.687, p .
H/S
14
135.1
19.7
142.4
19.0
7.3
0.180).
H
15
137.0
24.4
144.1
25.0
7.12
Dependent t-tests on arm and
M/S/R
16
115.2
13.4
117.9
13.5
2.7
Squat (kg)
thigh circumferences indicated
H/S/R
17
193.2
25.0
218.1
24.6
24.87
a significant increase across
H/S
14
196.6
27.6
210.9
26.8
14.13
groups (arm = t(1,61) = 2.04,
H
15
197.0
35.1
210.6
38.9
13.64
p = 0.046; thigh = t(1,61) = 7.22,
M/S/R
16
174.4
22.2
180.4
24.9
5.97
p , 0.000), but no change for
chest girth (t(1,61) = 0.34, p =
0.739). The ANOVA did not
Participants did not wear knee or elbow wraps during the
workout sessions. In addition, they were instructed to refrain
from any resistance training outside of football practice for
the duration of the study.

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Practical Blood Flow Restriction

Figure 2. Group 3 time interaction for 1 repetition maximum squat. * =


significantly different from the other 3 training groups (p # 0.05).

detect differences between groups for any girth measurement


(arm = F(3,58) = 0.946, p = 0.424; thigh = F(3,58) = 0.102, p =
0.958; chest = F(3,58) = 1.043, p = 0.381).

DISCUSSION
The purpose of this study was to investigate the effects of
a 7-week practical BFR protocol used in conjunction with
traditional weight training on measures of muscular strength
and size in collegiate American football players. We hypothesized that those who supplemented the traditional highintensity strength training program with the low-intensity
lifting protocol under conditions of practical occlusion
would experience greater gains in muscular strength and
size than those in the other treatment groups. The results
partially support the hypothesis.
The primary results of this study were as follows: (a)
H/S/R experienced significantly larger increases in 1RM
squat than the other training groups; (b) although there was
a significant increase in 1RM bench press across groups, the
addition of the supplemental lifting protocol, with or without
occlusion, made no difference in the extent of those gains;
(c) although thigh and arm size increased significantly across
groups, the addition of the supplemental lifting protocol,
with or without occlusion, made no difference in the extent
of those increases.
The supplementary low-intensity training protocol used in
this study to examine the BFR treatment was a modification
of that used by Yamanaka et al. (36), who also used a collegiate American football team as the testing population. Both
the Yamanaka et al. study and this investigation used a training load of 20% 1RM with a set and repetition scheme of
1 set of 30 repetitions, followed by 3 sets of 20 repetitions,
with 45 seconds of rest between each set.

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The differences were that Yamanaka et al. (36) used a 5.0cm wide elastic wrap (manufacturer not reported) and tightened to a 5.1 cm (2.0 in) overlap, whereas we used a 7.6-cm
wide wrap and used a 7.6 cm (3.0 in) overlap to achieve the
BFR. They used a cadence of 2.0:1.0 seconds for pacing the
eccentric and concentric components of each lift, whereas
we used a cadence of 1.5:1.5 seconds, based on work by
Yasuda et al. (38).
Also, they performed both the BFR squat and bench press
on the same day, as their 4-week program completed 3 totalbody workouts per week (36). Our 7-week program used an
upper- and lower-body split routine, with each being performed twice per week, for a total of 4 lifting days per week.
Therefore, the BFR squat and bench press lifts were on
separate days, each following the respective lower-body or
upper-body workouts.
Finally, their study used 2 training groups, both of which
completed the supplementary 20% 1RM lifting sessions,
although only 1 received the practical BFR wrap treatment
(36). We replicated this scenario with our H/S and H/S/R
groups. However, we incorporated 2 additional groups in an
effort to further clarify the potential effects of practical BFR
training in a well-trained population. Yamanaka et al. reported significant differences between groups in 1RM bench
press and squat performance gains, with those in the BFR
treatment group experiencing larger increases. In addition,
they also observed differences in chest size, with the BFR
group again seeing greater increases. The results of this study
only partially replicated the findings of Yamanaka et al.
Yamanaka at al. (36) reported that the BFR treatment
group experienced significantly greater gains in 1RM squat
than those of the non-BFR control group. This investigation
replicated that finding. Univariate follow-up tests to the significant interaction showed a significant difference for 1RM
squat, with the H/S/R group experiencing greater gains
than the other training groups (Figure 2).
This disproportionate increase was likely a result of the
use of practical BFR in conjunction with the low-intensity
supplemental lifting protocol at the conclusion of the
traditional high-intensity workout. A brief review of the
training groups aids in understanding this interpretation.
First, M/S/R also performed the supplemental lifts with the
practical occlusion application (i.e., the wraps), but completed only the modified training program, which excluded
any traditional high-intensity squat variations. This seems to
indicate that performing low-intensity BFR after highintensity training results in greater increases than can be
expected when performing BFR in the absence of highintensity training. Second, H/S completed the high-intensity
training and the low-intensity supplemental lifts, but not
under conditions of practical occlusion. Therefore, the
occlusion application appears to provide an additional
stimulus for strength gains beyond the low-intensity supplemental lifting protocol even when used in conjunction with
high-intensity training. Finally, the gains experienced by

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M/S/R and H/S were the same as those seen by H, who
completed only the traditional high-intensity workout. The
lack of difference among these 3 groups further supports the
concept that the additional gains seen by H/S/R are likely
the result of the combination of high-intensity training
followed by the low-intensity supplemental sessions under
conditions of practical BFR.
As with the 1RM squat, Yamanaka et al. (36) reported
significant increases in 1RM bench press performance, with
the BFR treatment group experiencing greater gains than
the non-BFR control group. This investigation did not support this finding. Because the MANCOVA showed a nonsignificant main effect for group, follow-up analyses were not
required. But as previously noted, additional analyses were
conducted to better understand how current results compare
to those of the Yamanaka et al. study (see Results). Although
the dependent t-test on 1RM bench revealed that there was
a significant increase across groups, the ANOVA did not
detect differences between groups. This indicates that in
reference to upper-body strength, neither the supplemental
lifting protocol nor practical BFR application provided any
additional benefit beyond what was experienced with the
traditional high-intensity training regimen.
One possible explanation for this is that the upper-body
high-intensity workout had already provided a maximum
stimulus for increasing strength and that the potential gains
often seen with BFR training were attenuated accordingly.
Wernbom et al. (33) noted in their review of resistance training that there appears to be a sigmoidal dose-response in
reference to training volume, whereas gains in muscle mass
seem to increase with greater volumes or durations of work,
but that there is a point of diminishing returns. They go on
to indicate that moderate volumes of work appear to result
in the largest responses. Although Wernbom et al. are referencing muscle mass and not strength per se, it seems reasonable that a similar dose-response would exist with strength
gains as strength is a property of the neuromuscular system.
Therefore, it is possible that the volume of the upper-body
high-intensity training protocol was near the peak of the
dose-response curve and that the additional dose provided
by the supplemental training volume and/or the BFR occlusion stimulus could not elicit further response.
Although the high-intensity workout may have provided
sufficient stimulus for strength gains in H, H/S, and H/S/R,
it does not explain the gains experienced by M/S/R, who
only completed the modified training protocol before the
BFR training. It is possible that the BFR application could
account for the strength gains, which has been demonstrated
previously in trained populations (3,30,36). However, in the
absence of a non-BFR, modified training group with which
to compare, it can only be speculated.
Another possibility is that although M/S/R did not
perform any of the traditional high-intensity lifts, they still
completed a substantial amount of total work. The overall
volume of BFR training sessions can be quite high even

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though BFR training is often described as low-intensity


work. Defining workout intensity by the percentage of the
1RM (%1RM) of a given lift for an individual is common and
is often referred to as relative intensity (9). But, although
BFR training typically uses a low relative intensity of 20
30% 1RM, the work volume for a session of BFR exercise
can be substantial and possibly comparable to the work volume of a traditional high-intensity session. For example,
a bench press 1RM of 100.0 kg would dictate a barbell load
for a BFR session using 20% 1RM to be 20.0 kg. If the BFR
protocol was identical to that used in this study, a total of 90
repetitions with that load would be performed, resulting in
an exercise volume-load (repetitions 3 weight) of 1,800 kg.
If a more traditional high-intensity workload of 80% of that
same 1RM (80.0 kg) were used to complete a typical highintensity workout of 4 sets of 6 repetitions, the total exercise
volume-load would be 1,920.0 kgonly 120.0 kg more than
the BFR session. Therefore, it is plausible that the volumeload completed by M/S/R was high enough on the doseresponse curve that strength gains resulted, despite the
absence of using a high relative intensity.
Although research generally indicates that traditional
high-intensity programs are superior for strength gains,
there is some work that suggests that using a low relative
intensity along with higher repetitions may also be effective
at promoting strength, provided enough volume is used,
even in the absence of BFR (26). However, because total
workloads for each participant were not calculated for this
study, this remains speculative.
The possibility that the upper-body high-intensity training
program alone may have provided a maximal strength gain
stimulus is also supported by observations made during this
study that seem to oppose those made by Yamanaka et al. (36)
in their investigation. They stated that all participants in their
study were able to complete every repetition in the supplemental protocols and that personal conversation with the
participants after the sessions indicated that the players felt
that the number of repetitions was not sufficient for them to
reach exhaustion. Interestingly, our observations during this
study were quite different. Although no data were collected
on repetitions completed, we observed that some participants
had to pause or skip a repetition during the supplemental
lifting sessions. Personal discussions indicated that these participants were simply getting fatigued and needed a brief
respite to continue. Although this was only occasionally seen
during the squat exercise, it was more common during the
bench press sessions. This was true for participants who were
in both H/S and H/S/R (non-wrapped and wrapped), which
indicates that the fatigue could not have been because of the
use of the practical BFR wraps alone.
This is also supported by our observations that those in
M/S/R did not skip repetitions during the sets, even though
they were also using the elastic wraps in the same manner as
H/S/R. Because M/S/R completed only the modified
training program before BFR training (i.e., no high-intensity
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Practical Blood Flow Restriction


squats, bench press, or their variations), it suggests that the
fatigue experienced by H/S and H/S/R was more likely
a result of the high-intensity training program that they
completed just before the supplemental training, rather than
the extra lifting sessions and/or the BFR wraps. Although
Yamanaka et al. (36) did not report the details of the strength
and conditioning program used in their study, it seems reasonable to surmise that it was of a lower overall volume than
the high-intensity training program used by H, H/S, and H/
S/R in this investigation. The volume of the workout and
BFR training protocol used by Yamanaka et al. may have been
sufficiently low enough on the dose-response curve that the
extra stimulus provided by the BFR wraps was able to produce an increased response.
In reference to the work volume-load of the lower-body
sessions, H/S/R did experience a greater increase in 1RM
squat compared with H and H/S. This suggests that the highintensity lower-body training program did not provide
a maximal stimulus for strength gains. Therefore, the volume
was likely lower on the dose-response curve relative to the
upper-body training, allowing for the addition of the practical
BRF application to elicit a greater strength response.
Similar to Yamanaka et al. (36), this investigation employed the use of girth measurements in an effort to assess
changes in muscular size, namely at the thigh, chest, and
upper arm. The aforementioned study observed increases
in chest girth but not thigh or arm girth. Thefindings of this
investigation were contrary. As with the 1RM bench press,
the MANCOVA revealed no interaction for group on circumferences, so additional analyses were conducted to better compare current results to those of Yamanaka et al. (see
Results). The dependent t-tests on arm and thigh circumferences indicated a significant increase across groups, but no
change for chest girth. The ANOVA did not detect differences between groups for any girth measurement. So, while
there was no change in chest size, there were small but
significant increases at the thigh and the arm across groups,
but no differences among the treatments. However, the practical significance of these results for changes in girths becomes questionable when consideration is given to the
magnitude of the changes, as can be seen in Table 4.
This study was not without limitations. Because of using
elastic knee wraps in a practical manner to achieve BFR,
knowing the precise pressure actually applied to each
participant was not possible. Benefits from BFR occur when
there is adequate pressure to occlude venous return, but yet
only restrict arterial delivery (25). Wilson et al. (35) have
shown that elastic wraps (7.6 cm wide) applied with a perceptive pressure of 7 on a scale of 010 are effective at
allowing a restricted arterial flow while occluding venous
return in the thigh muscle.
Perceptive pressure is a subjective measure and will likely
differ among individuals and may even vary for each person
on a day-by-day basis. Yamanaka et al. (36) used a 5.1 cm
(2.0 in) overlap to achieve BFR in their study but did not

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report on the procedure used to determine that degree of


tension. Before the start of our training program, we recruited 4 athletes in an effort to standardize the elastic wrap
pressure to be used in the study. We explained to them the
concept of the 010 scale of perceptive pressure and how to
use it in reference to wrap pressure (35). We then applied
a wrap to the upper leg with just enough tightness to remain
in place (perceptive pressure = zero), and a note was made
of the location of the end of the wrap. Then, the wrap was
slowly pulled tight until the participant indicated that the
tightness had reached a perceptive pressure of 7. The wrap
was then secured in place. The difference between where the
end of the wrap was before the tightening to where it was
secured after the tightening (i.e., the overlap) was measured,
on which the wrap was removed.
This procedure was repeated with every participant and
each required a slightly different overlap to reach a perceptive pressure of 7. The overlaps were then averaged, with
a result of approximately 7.0 cm (2.75 in). Following the
same procedure on the arms, we found an average overlap of
approximately 6.6 cm (2.60 in). We concluded that an
overlap of 7.6 cm (3.0 in) for both the upper body and
lower body during the study would likely be sufficient to
obtain a perceptive pressure of 7 for most of the participants
in the study. The use of a single overlap measure for both
applications also simplified the procedures and reduced
potential errors in applying and tightening the wraps.
Another potential limitation is that the participants in this
study were well-trained, male, collegiate American football
players. The results might not be generalizable to other
athletic populations, non-athletes, or those who are weighttraining novices.
Future research should examine high-intensity programs
of various work volumes and their relationship with the
effects of concurrent practical BFR programs. This could
provide additional insight into determining whether a doseresponse does exist when the 2 are used in conjunction and if
so, where the point of diminishing returns can be expected. If
it is found that practical BFR, when used together with
lower volumes of high-intensity work, can elicit strength
gains that are similar to, or exceed those typically observed
with traditional higher volumes of high-intensity work, then
this could have implications for future program design.
A lower overall training volume and/or lower external load
may allow athletes to recover faster, reduce their risk of
injury, and lessen their chance of overtraining. Taken
together with an increase in strength, this could translate
to improved athletic performance.
Investigating the dose-response in the context of in-season
strength and conditioning programs would be especially
relevant as these programs normally reduce volume as focus
shifts from strength training to actual competition. This shift
generally results in athletes experiencing declines in strength
as the season progresses. An effective combination of low
volume, high-intensity work and practical BFR may result in

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the maintenance or increase of strength during the competitive season, which is typically not experienced.
Also, limb size and possibly body composition appear to
play a role in how much pressure is needed to achieve
adequate BFR (19). Therefore, additional research should
examine how to best individualize perceptive pressure when
using practical BFR, for both the lower- and upper-body
applications.
In conclusion, this study demonstrated that the use of
a practical BFR program in conjunction with a traditional
high-intensity off-season training program was effective in
increasing 1RM squat performance in well-trained collegiate
athletes.

PRACTICAL APPLICATIONS
The results of this study indicate that practical BFR training
can be effective in increasing 1RM squat performance when
added to an off-season, high-intensity collegiate American
football strength and conditioning program. Elastic powerlifting knee wraps are relatively affordable and easy to use
compared with traditional BFR methods. This reduction in
the cost and complexity typically associated with BFR
training provides athletic programs, teams, coaches, and
athletes an increased opportunity to incorporate BFR into
their strength and conditioning programs.

ACKNOWLEDGMENTS
The authors would like to thank the Emporia State
University football team and coaching staff for their participation and dedication to this study. Also, we would like to
thank the ESU Research and Grants Center and the ESU
Teachers College for their help in funding this project.

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